Overall, descriptive clinical data from the shelter-based clinic described in this paper illustrate the need to identify alternative strategies for retaining homeless youth in mental health treatment. Although preliminary data suggest that some youth are motivated to return for follow-up care, there is nevertheless a sharp decline in the number of youth who attend more than one (i.e., intake) session. Consistent with previous literature [8, 15], results from this sample of youth also suggest that mental health concerns are high, with depression, anger, and adjustment disorder emerging as the most common presenting mental health concerns identified by clinicians in the intake appointment. The development of future mental health treatment programs needs to account for potential barriers to care while being sensitive to the unique mental health needs that youth disclose to providers during the intake process. Of note, trauma was not identified as a primary concern until the second visit which suggests that trauma may often be related to homeless young adults’ presenting complaints but may take additional time to uncover. Youth may also not feel comfortable disclosing traumatic experiences to a new provider in the intake session. Of note, the lack of clinically and statistically significant findings in reductions on the Clinical Global Impression Scale (CGI) are not surprising; since the average number of sessions was 3 and the first session was primarily an intake session, we would not expect to see clinically meaningful symptom reduction in such a few number of sessions. Future directions may evaluate whether there are other important changes that occur outside of symptom reduction, such as improved trust in providers or increased willingness to participate in future mental health treatment.
When developing future interventions for this population, it is important to keep in mind the treatment goals of the youth and/or the case management team. Anecdotally, many of the case managers at the Night Ministry identified substance use as a primary treatment target they would like the clinicians to address. However, as the data presented in this paper show, very few youth identified substance use as a presenting concern (and none did so in the first session), thereby illustrating a clear disconnect between the assumed needs and treatment targets of the youth and of the support staff working in the shelters. If additional substance use interventions are designed to specifically target homeless youth, it would be helpful to address these specific concerns from a motivational interviewing framework to increase buy-in and acceptability.
Similarly, while anger was identified as a common presenting complaint in the intake session, very few youth followed up for anger management in subsequent sessions. It could be that youth with severe anger problems were dismissed from the program for behavioral/safety concerns, or that they attended the intake session at the request of their case manager, but had no interest in engaging in services beyond the first session. One limitation of this study was the providers’ inability to follow-up with youth post-discharge from the program to identify ongoing mental health needs, but properly addressing this limitation requires that several important issues be considered. Balancing the needs of shelters (i.e. managing disruptive behavior, aggression and conflicts amongst residents) with the rights of young adults (i.e. autonomy, shared decision making, and prioritizing basic survival needs) can be quite challenging. On one hand, shelter staff have an obligation to maintain a safe, secure space for all residents. However, on the other hand, most of the residents are legally adults who have the right to refuse shelter staff’s mandates to seek mental health treatment and take prescribed medication. This disconnect impacts treatment referrals as well as commitment to follow up. This conflict in priorities also places mental health providers in the middle of complex ethical issues. Mental health providers have an ethical obligation to offer informed consent that is not connected to keeping housing or other basic needs despite shelter rules that might require adherence to treatment as a condition to remain in the shelter. Navigating the space between shelter staff and residents’ needs creates an opportunity for mediation, advocacy, and psychoeducation.
While not a primary focus of the paper and beyond the scope of services available in the clinic at this time, it is important to recognize the high frequency of self-reported head injuries by youth in this sample. The associations between head injury and both cognitive and emotional sequelae have been long well-established in the medical literature, and this relationship is dependent both on severity and frequency of the injuries [39, 40], and may be underlying some of the problems that drove youth into homelessness and are further perpetuating the cycle of homelessness. Thus, in addition to traditional outpatient therapy, it is important to find ways to increase access to neuropsychological testing and related services (Individualized Education Plan/504 Plan support, etc.). Likewise, future work should also include an assessment of psychiatric services offered to homeless youth in this and similar clinical settings to evaluate whether youth engage with psychiatric services differently than with psychological resources.
Of the twelve youth who were seen for more than 6 sessions, five were in the long-term (24-month) housing program. Two of the youth were diagnosed with severe mental illness, and required regular mental health consultations as part of their case management care plan. It is possible that the youth in the 24-month program experienced less pressure to find housing and had stable employment/schooling (a requirement to remain in the long-term program), and therefore had more stability to benefit from ongoing mental health treatment. In contrast, youth in the short-term housing programs were often working to find long-term housing, interviewing for/seeking out jobs, and some were attending school. Scheduling therapy around these competing demands can be a logistical challenge. Challenges with mental health may prevent youth from being successful in their academic and career endeavors.
Based on the findings from this sample, it appears that simply addressing a logistical barrier (i.e., convenience/clinic location) is not enough to significantly improve patient retention in mental health services. An important limitation of the present study is that, to date, scheduling and communicating with youth between sessions has been largely facilitated through case managers. In the future, clinicians in our program may explore means of more direct contact with youth if they are interested in providing contact information for follow-up after the first session. Text message-based appointment reminders and communication may also facilitate follow-up [41, 42]. Related to this point, it is important to evaluate specific reasons why youth did not follow-up for services in the clinic. Before targeted approaches are developed, it is important to know what services youth want, what they are willing to engage with, how logistical barriers can be more effectively overcome, and how youth can remain engaged beyond the first session. Future research should explore how targeted approaches can be integrated into other programs such as education attainment and/or job placement.
Similarly, a future research direction is to complete focus groups or individual interviews with homeless youth to gather additional qualitative information on service utilization. While previous studies have established that there are high rates of mental health problems in this population, our work suggests that retention in services is an equally important problem. Youth should play an active role in evaluating ideas for future treatment development, as previous work has demonstrated the need to better understand the specific perceptions of and attitudes toward mental health and treatment options in order to increase quality mental health care for higher-risk populations.
One proposed strategy for reaching youth more consistently has been to harness technology to disseminate empirically-based mental health tools to youth. For example, previous studies have found high acceptability of a cell-phone based intervention in which youth were provided with phones and data plans for 1 month . The phones came preloaded with mental health apps designed to address mood regulation, sleep, and teach basic cognitive-behavioral principles. Youth were also given the option to schedule three, 30-min phone therapy sessions with a doctoral-level therapist. Youth reported high levels of satisfaction with the study (i.e., 70% reported being moderately-to-extremely satisfied with the study, and 90% would recommend participation in the study to others), and most utilized all three 30-min phone therapy sessions. In a fully-automated follow-up to this study, youth also reported being very willing to engage with the features of the intervention. Thus, these data collectively illustrate that technology can provide a fruitful avenue by which mental health services can be provided to youth, particularly those who are unstably housed and have the greatest number of barriers to formal care. Future research should more closely evaluate whether these fully automated programs are equally efficacious to clinical standards-of-care (e.g., Cognitive Behavioral Therapy).
Given the limited time homeless youth engage in mental health care, interventions tend to be brief and supportive in nature. Although a specific intervention or approach might be indicated for the presenting problem or diagnosis, without a commitment to ongoing treatment, mental health providers are faced with choosing an eclectic approach instead of what is indicated. Some might argue that a non-empirically based intervention is better than no treatment at all. Utilization of a transdiagnostic model may offer some guidance in these situations . Models like the Common Elements Treatment Approach (CETA) teach patients eight key cognitive behavioral tools that have been found to yield positive clinical outcomes. This approach has been successful among individuals experiencing trauma-related disorders [45, 46] and in low resource countries , thereby making this approach particularly useful for homeless youth.
An alternative view is to conceptualize the first session as the primary intervention point, and to therefore focus clinical research efforts on designing brief, targeted, and single time-point interventions for this population. The greatest attention should be paid to developing clinical tools that target depression and trauma, as these are among the most-commonly reported mental health concerns both in this sample and in previously-studied representative samples of homeless youth across the United States [5, 6, 9]. Relatedly, previous qualitative research with youth residing in supportive housing has demonstrated the importance of designing housing programs that directly address needs of youth who are working on building their self-efficacy and independence, and who sometimes report feeling like they receive mixed and inconsistent messaging regarding the need to develop greater autonomy while simultaneously being expected to abide by very strict rules (characteristic of being treated like a child) . If we extrapolate these findings on attitudes on supportive housing to the findings presented here, it would appear that youth may prioritize services that focus on supporting their independence and building self-efficacy that they have not had in the past over targeting specific mental health diagnoses or conditions. Again, future qualitative research with youth in the shelter may help us better identify factors that motivate ongoing mental health treatment in this population.
Likewise, given the high levels of mistrust toward adults and the mental healthcare system , clinicians should consider finding appropriate ways to engage youth in serving as bridges to formal mental health care, such as through the creation of youth mental health ambassador programs. Clinicians working with homeless youth and other historically-marginalized populations may also consider explicitly measuring cultural mistrust, such as through tools like the Medical Mistrust Index (MMI ;), to gauge how much time in therapy needs to be spent on directly addressing this issue as a way to potentially increase compliance in follow-up care. These programs could be loosely based on the Friendship Bench model [49,50,51], which has shown promising results in developing countries where access to empirically-based care is limited, or on the CETA model described above, which has been used by lay mental health workers in developing countries . Briefly, the Friendship Bench program trained laypersons in the delivery of an empirically-supported mental health treatment program for common mental health disorders (e.g., depression, anxiety, etc.). Laypersons were formally supervised by licensed mental health professionals. Youth “ambassadors” may have greater social clout than licensed professionals, particularly in cases where youth have had adverse experiences with the social justice system (including mental healthcare workers, juvenile justice, etc.), and could therefore serve as liaisons in the reintegration of underserved youth into the mental healthcare system . To the authors’ knowledge, such programs have yet to be developed and evaluated in the United States, but data from low- and middle-income countries suggest that utilizing laypersons helps to build trust in, and expand access to, the mental healthcare system. In any case, greater priority needs to be taken to directly measure and assess these needs among young adults specifically , as opposed to extrapolating findings from the adult and adolescent literatures for this transitional age group. Similarly, as has been identified in previous studies, rather than simply focusing on determinants of program engagement, future iterations of clinical service models for homeless youth need to focus on identifying appropriate ways to communicate with youth ], particularly around issues of initiating and sustaining mental health treatment.